Effective Practices in Teen Pregnancy Prevention

1. Effective Practices in Teen Pregnancy Prevention Kevin G. Tobin, Ph.D. Westfield State College Mary Jean O’Reilly, Ph.D. Pittsfield Public Schools Benjamin Solomon,M.Ed. University of Massachusetts at Amherst Craig Wells, Ph.D. University of Massachusetts at Amherst NASP Convention March 2010

2. Purpose of the Study • The purpose of this study was to evaluate the effectiveness of two evidence based programs that purport to reduce adolescent sexual risk-taking behavior. • The second goal of this study was to determine the value of the Transtheoretical Model of Change (Prochaska, DiClimente, and Norcross, 1989) for understanding the stages of and processes of change for adolescent sexual risk-taking behavior.

3. The Costs of Teen Pregnancy Teenage pregnancy has enormous individual and social costs according to the National Association of School Boards (2000). 70% of teen mothers drop out of school and only 30% complete high school by age 30. The majority of teen mothers live in poverty during the first decade of their children’s lives. Over 80% of teen mothers depend on welfare at some time during that decade.

4. Risk Factor Reduction Some researchers in the field of teen pregnancy prevention have focused on providing teens with a more realistic view of the challenges of parenting, evaluating the connection between teens’ goals and future plans and reduced rates of pregnancy, and helping teens develop sexual self-efficacy (Somers, Johnson & Sawilowsky, 2002).

5. Evidence-based prevention • A scientific approach to preventing teen pregnancy includes: • The use of research to identify risk and protective factors • Determining which factors to address and how to address them • selecting evidence-based programs (EBP) • EBP includes: cultural sensitivity, theory driven practice, a focus on positive skills, appropriate timing, and appropriate dosage (Nation et al., 2003) • Evaluating the success of the programs (Lesesne, Lewis, White, Green, Duffy & Wandersman, 2008).

6. Continuum of Interventions to address teen pregnancy, early sexual activity, and STD’s Individualized Intensive Interventions Tier 3: Intensive Interventions For high-risk students Include SAC services and peer mediation Targeted Group Interventions Tier 2: Strategic and Targeted Interventions for Students At –Risk include After-School Programming, After-School small group health education groups Strategic Interventions for Students at Risk of Academic Failure Tier I: District-Wide Primary Prevention for All 8th, 9th and 10th Grade Students Includes The “Making Proud Choices” and “Safer Choices” Curricula Presented in Health and Human Development Classes Universal Interventions

7. Making Proud Choices in Middle School Making Proud Choices is an evidence-based curriculum designed to decrease the risk of sexually transmitted diseases, including HIV and other sexually transmitted diseases, and to reduce the rate of unintended pregnancy among teenagers. This curriculum educates adolescents about their own vulnerability to these risks, and teaches effective prevention strategies. The curriculum provides instruction for adolescents in the skills needed to use condoms effectively whenever they are sexually active.

8. Making Proud Choices in Middle School • The Making Proud Choices curriculum consists of eight units. Topics include: • future goals and plans • possible health and life consequences of unprotected sex • strategies for preventing HIV infection involving stopping, thinking and acting thoughtfully • negotiation skills for condom use • sexual refusal skills and negotiation skills.

9. Safer Choices the High School Program Safer Choices curriculum was adopted for use at the high school level. This curriculum is designed to reduce the number of students engaging in unprotected sexual intercourse.  Safer Choices promotes the message that unprotected intercourse or intercourse before one is ready is an unsafe choice. protection against pregnancy and STDs is a safer choice, choosing not to have intercourse is the safest choice. 

10. Safer Choices the High School Program The Safer Choices curriculum focuses on school wide change, through the creation of a school health promotion council and a Safer Choices peer team.  Both of these groups plan school wide events designed to change student practices and culture.  Students learn about support services available in their community.

11. Survey 2007-2008 In 2007-2008,The Student Change Survey and the POSIT were administered to: 95 eighth graders in middle school 288 ninth, and tenth grade students from the two high schools in the district 25 students to students who attended an Alternative program 8 students who attended the Teen Parent Program.

12. Survey in 2008-2009 The Making Proud Choices /Safer Choices Survey were administered during health classes to 344 eighth graders in Middle School, 233 ninth graders, 166 tenth graders, 13 eleventh grade and 9 seniors In 2008-2009, a total of 844 students were surveyed 23 students had missing data

13. Demographics of the District African American 10.4% Asian 1.6% Hispanic 7.2% Native American 0.3% White 77.7% Multiracial 2.8%

14. Demographics of the District Small Northeast City City Population 42,631 Number of students 6,108 8 Elementary Schools 2 Middle Schools 2 High Schools 519.1 teachers Teacher Student Ratio 11 to 1

15. Treatment Fidelity Each presenter of the Making Proud Choices program was asked to complete the Making Proud Choices Implementation scale for each session they conducted. The results indicate that all presenters completed the implementation scale for all sessions that occurred. An independent observer who was trained in the programs observed several presentations of the programs. The results indicate that the set up and preparation for the modules was quite good. The format of the lesson was followed faithfully and presented fluently.

16. Survey Administration The POSIT and Student Change Survey were administered at one week before the evidence-based programs were used by the health teacher, the school adjustment counselor, or peer resource staff And after the 10 weeks of Making Proud Choices lessons or Safer Choices were presented.

17. Problem Oriented Screening Inventory The Problem Oriented Screening Inventory or POSIT was authored by the National Institute on Drug Abuse (NIDA) at the National Institutes of Health (NIH). It consists of 89 self-administered yes/no questions. POSIT was designed to identify problems and treatment needs in 10 areas, including substance abuse, mental and physical health, and social relations, and is designed for adolescents with at least a fifth grade reading level. Additional items were added to the version of the POSIT used for this research in order to better assess the sexual attitudes, knowledge, and behaviors of teenagers

18. The Student Change Survey This survey was developed by Kevin Tobin, Ph.D., and investigated students’ stages of change using a Transtheoretical Change Model (Prochaska & DeClemente, 1984). This model describes the four key stages of change as precontemplation, contemplation, action, and maintenance. This model provides a way to describe and analyze the change process that can be used to address students’ needs and increase their self-awareness as they develop more effective strategies to manage sexual situations.

19. Stages of Change Students in the first stage, precontemplation, do not consider themselves to have problems with sexual activity or substance abuse, and are not thinking seriously about changing their behavior and/or may lack information about the consequences of their behaviors. At the contemplation stage students may be more open to talking about issues and reading material about their problems or concerns, although they may not yet be ready to take action to change their current behaviors.

20. Stages of Change In the preparation and action stages, students begin to change problem behavior and may need support to understand how to change their current habits and practices. Training around effective communication in relationships helps students learn the skills needed to make specific behavioral changes. In the maintenance stage, changes in behavior are maintained over time. Continuing support for positive choices around peer groups and after school activities can help students to maintain healthy behaviors.

21. Sample Questions • 17.Do you AVOID unprotected sex that could lead to HIV/ AIDS or another sexually transmitted infection? • YES, I have been for MORE than a semester. • 4 YES, I have been, but for LESS than a semester. • 3 NO, but I intend to in the next month. • 2 NO, but I intend to in the next semester. • 1 NO, and I do NOT intend to participate in the next year. 7. Have you quit smoking cigarettes? 6 I was NEVER a cigarette smoker. 5 YES, I quit MORE than a semester ago. 4 YES, I quit LESS than a semester ago. 3 NO, but I intend to quit in the next month. 2 NO, but I intend to quit in the next semester. 1 NO, and I do NOT intend to quit in the next year.

22. Previous Research There has only been one published study using the Transtheoretical Model of change to assess the sexual behavior and attitudes towards condom use among adolescents. Wallace, Evers, Wareing, Dunn, Newby, Paiva and Johnson (2007) surveyed 3800 school children in England between 13 and 16 yearsabout sexual activity using the TranstheoreticalModel (TTM) Stages of Change.

23. Results of Previous Research A quarter of teens were sexually experienced, 44.8 per cent did notuse contraception, and 48.9 per cent did notuse condoms, every time. Past history of condom and contraceptiveuse, and partner willingness to use condomswere the best predictors of being in Action or Maintenance stage for condom use. Of virgins, 19.82 per centwere in Contemplation or Preparation stagesfor intercourse, and 85.4 per cent would use condoms every time.

24. Study Methods • Quasi-experimental longitudinal design • Confidentiality prohibited data tracking of individual students across time using statistical analysis • However, based on post-test data, we could account for fidelity using categorical questions asked, and compare this data to POSIT scores • Easiest solution was to combine fidelity measures and model it against POSIT scores • Students who went through most components should have highest POSIT scores.

25. Study Methods • Combination of factors linked to survey scores is well suited for structural equation modeling. • Self-reported group membership was dummy coded and combined to form a latent variable, “resiliency” In this instance, a mixed model was used • Resiliency as a latent exogenous variable • The POSIT and individual fidelity questions as the measurement model. • Pre-Post differences were handled descriptively

26. Results – Statistical Analysis The POSIT is reported to have a seven factor structure CFA indicated this may not hold for our sample

27. Pre-Post (Mixed) Model χ2 = 1449.45 df = 1030 RMSEA = .10 NNFI = .96 Factor 1: Hostile Attributions Factor2: Adult Attachment Factor 3: Healthy Sexual Behavior Factor4: School Attachment

28. CFA on Student Change Survey χ2 = 379.48 df = 129 RMSEA = .07 NNFI = .97 Factor 1: Healthy Sexual Behavior Factor2: Substance Abuse Factor 3: Communication and Delay Strategies Factor4: Positive Student Behavior

29. Avoiding Unprotected Sexby Gender Percent

30. Coincidence of Unprotected Sex with a Positive Relationship with Parents

31. Report of Condom Use 2007-2008

32. Use Condom to protect from Pregnancy 2008-2009

33. Use Condom to Protect from HIV 2008-2009

34. Social Norms: My friends believe it is OK to have sex with boyfriend / girlfriend 2008-2009

35. Avoiding Risk 64 percent of students think that wearing condoms is extremely important to protect oneself from pregnancy 90 percent of students think that condoms are extremely important for protecting them from HIV or and STD. This is the KEY Motive to change behavior in this population. Our curricula target this motive.

36. Conclusions Significant, yet practically small effect sizes were noted on the post-test in regards to student hostile attributions and school attachment. The student change survey may serve as a valid indicator of readiness for change and should be considered as an outcome tool for behavioral interventions. The POSIT, while useful and broad-based, may need to be reconsidered in regards to its factor structure for certain populations. Descriptive analysis showed students increased their belief in the importance of condoms and increased their endorsement of healthy sexual behavior over the course of one academic year.

37. Future Directions Revision of the Change and Posit Survey χ2 = 2646.22 df = 614 RMSEA = .06 NNFI = .97